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GIVING GPs feedback about how their test ordering impacts on the health care system will help achieve cost containment, says a leading Australian public health academic.
Professor Janet Hiller, associate dean and professor of public health at the Australian Catholic University in Melbourne, told MJA InSight that GPs “think in terms of the individual patient in front of them” and don’t “multiply up”.
Professor Stephen Duckett, professor of health policy at LaTrobe University and the Grattan Institute in Melbourne, said it was “always important to be careful with our resources”.
“There will be increasing costs [but] if we want to protect universality, the best way to protect the public system is to keep it efficient. There must be a balance between the health of the individual patient and the cost effectiveness of the treatment”, he told MJA InSight.
Professor Hiller said Australian GPs were given very little feedback about the impact on the health care system of over-testing and unnecessary procedures.
“We could do better if we could have, for example, desktop software that tells a GP how many times they’ve ordered a particular test and the dollar value of those tests.”
She also agreed that a way of comparing a GP’s ordering behaviour with that of other GPs would be useful.
“There isn’t one person with a script pad in this country who doesn’t know the cost effectiveness of the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme”, Professor Hiller said. “It’s the next step [in awareness] that we don’t have yet.
“We are a few steps ahead of the US in this, however.”
Professor Hiller and Professor Duckett were responding to research published in JAMA last week detailing the views of US physicians about controlling health care costs. (1)
The cross-sectional 2012 survey of 2556 US physicians randomly selected from the American Medical Association membership, found that only 36% felt that practising physicians had a “major responsibility” for reducing health care costs.
Trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%) and patients (52%) were seen as the ones with the most responsibility for cost containment.
The study also found that while US physicians were enthusiastic about “motherhood” concepts such as “promoting continuity of care” (75%) and “expanding access to quality and safety data” (51%), they were much less willing to support more targeted reforms which impacted them personally, such as “eliminating fee-for-service payment models” (7%).
An editorial in the same issue of JAMA, coauthored by leading US bioethicist and advocate for voucher-based universal health care, Ezekiel Emanuel, said physicians were in “denial of responsibility”. (2)
“Unless physicians want to be marginalized … they must accept and affirm that they are responsible for controlling health care costs”, the authors of the editorial wrote, while acknowledging that at least US doctors had moved beyond denying health care costs were a problem.
“Physicians must commit themselves to act like the captain of the health care ship and take responsibility for leading the US to a better health care system that provides higher quality care at lower costs.”
AMA president Dr Steve Hambleton told MJA InSight the suggestion that physicians were in denial about their responsibilities was overly harsh and not indicative of the Australian situation.
“I don’t see a cause for negativity in this research”, he said. “Doctors are clearly saying that there needs to be a conversation nationally about health care costs. We need to make rational decisions about what we can deliver ― how we can help the most people, most of the time.”
Dr Hambleton said Australia’s ageing population and the rising need for and costs of chronic disease management meant reforms and cost containment were realities to be faced, not just in Australia, but around the world.
1. JAMA 2013; 310: 380-388
2. JAMA 2013; 310: 374-375
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In comparison to New Zealand, the bulk billing of patients [encouraged by politicians, corporates and patients] is a disgrace to proper medicine. Combine the very short consultations with a litigation just around the corner and you have recipe for over-ordering tests and prescriptions. Hence the rising health costs.
Although it has its faults, the Accident Compensation Corporation system used in NZ since 1974 has effectively curtailed substatntial litigation. There is still Medical Council / Health & Disability commisioner investigations and fines/restrictions to inappropriate medical actions or doctors.
Capitation of patients provide a steady Government subsidy to patients registered [this encourages continuity of care] to a Doctor or Practice. In association with part-payment by patients it encourages practices to efficiently manage greater numbers of patients per doctor with greater assistance from Practice Nurses.
Without accurate statistics a NZ Doctor is likely to look after between 2000 to 5000 patients each and there would usually be a 1:1 Doctor/Nurse ratio.
Practice Nurses manage certain issues/patients themselves.
Consultations are booked 15 minutes apart to give appropriate time to sort out issues.
Bulk billing with very poor attendance fees are the reason Doctors have to see 60-70 patients/day at 6-7 min intervals. It is also the incentive to overuse some procedures. Bulk billing in association with litigation and Medicare/PBS rules are also the reason behind every patient being seen by every doctor for every attendance. eg one medication item at a time, referrrals, reviewing results. Hence a 1:4 Nurse-Dcotor ratio.
Countries can learn from each other !
As long as we are made to practise defensive medicine, there will always be lots of investigations
In a resource constrained environment where we are trying to maximise patient benefit and control costs there is much talk about where care is delivered. This is very important in the HIV, viral hepatitis and sexual health medicine areas. As treatments get more manageable and hospitalisation are reduced, the reliance on specialist services decreases for many people. How that care works and working out who does what is crucial.
At ASHM we have been involved in a number of programs where care is transfered to the GP or where care is shared between specilaist and primary care providers. What we have often seen is the replication of pathology tests done in one setting by the provider in the other. This is not just an issue for GPs but also for hospital based specialists when care is shared with a general practitioner.
Requesting results be copied to both the specialist and the GP can reduce this burden on the health system. It also reduces the burden on the patient and demonstrates the respect that health care providers have for their colleagues. Cycle of care schedules and treatment guidelines can all contribute to setting appropriate testing frequency, minimising duplication and the minimising the associated costs.
Rein in the legal profession & you will help contain costs, especially with investigaions.